Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0176, written 7 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Apr 2025 |
|---|---|
| Reference | 2025-0176 |
| Deceased | Christian Hobbs |
| Coroner | David Heming |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North West Anglia NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 8 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. North West Anglia NHS Foundation Trust ( NWAFT) 2. Cambridgeshire and Peterborough ICB ( CPICB) 3. Department of Health and Social Care 4. Department for Digital, Culture, Media and Sport 5. Northamptonshire Children Safeguarding Partnership 6. Royal College of Emergency Medicine 7. Faculty of Intensive Care Medicine 8. Royal College of Radiology 1 CORONER I am David Heming, Senior Coroner for the coroner area of Cambridgeshire and Peterborough. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 9th January 2018 an investigation was commenced into the death on the 26th December 2017 of Christian James Gabriel Hobbs (aged 17 years). The investigation concluded at the end of the inquest on the 14th October 2024 and some key determinations were :- Medical Cause of Death : 1a. Multi Organ Failure 1b. Cardiogenic Shock 1c. Arrhythmogenic cardiomyopathy Conclusion: Died from complications following an acute deterioration having decompensated Regulation 28 – After Inquest Document Template Updated 30/07/2021 over a short period of time on a background of a previously undiagnosed pre-existing arrhythmogenic cardiomyopathy. 4 CIRCUMSTANCES OF THE DEATH 1. 2. 3. 4. 5. Christian had no known relevant past medical history. He was at school and had a passion for and love of boxing from a young age. He was a member of a boxing club. His father, who had served for 10 years as an infantry officer in the Army said that he had seen fit men, but Christian was amongst the fittest he had seen. The Christmas period in 2017 had led to a large gathering at the family home in Northamptonshire. On Christmas day, Christian seemed fine before lunch and a photograph had been taken. He was said to have been in good form over lunch but went inside as he was not feeling well. It was not considered that he had anything other than a suspicion of flu. When checked the following day, he seemed much the same at circa 12 noon and he was adamant he still wanted to go on holiday. He had taken paracetamol and Ibuprofen. He was checked again in the late afternoon and his mother then asked his grandfather (a retired Consultant) to look at him because of some concerning features. His grandfather found his conscious level to be ‘tenuous’. He considered him to be clammy and shut down. The radial pulse was not palpable and the carotid pulse was circa 240. He considered Christian was morbidly white and had no capillary return. As a result, Christian’s parents urgently transported him by car to the City Hospital, Peterborough. Christian told his mother on the journey that his heart had been going fast since after lunch the previous day and had a sound of rushing blood in his ears like he had been on a long run. His grandfather telephoned the hospital and spoke to a receptionist and pre- warned about his arrival and relayed concerns about the heart rate, the poor perfusion and ‘the prejudiced cardiac output’. ADMISSION TO PETERBOROUGH CITY HOSPITAL 26/12/2017 6. 7. Christian was documented as having arrived in the Emergency Department (ED) at 17:42. Christian was seen by the assessment nurse on recorded entries at circa 17:45 where the presenting complaint was documented as?AF/?SVT. It was also documented that Christian had complained of chest tightness and vomiting and that he had already taken paracetamol and ibuprofen. 8. Observations documented a heart rate of 159 (with a recorded entry of 240 Regulation 28 – After Inquest Document Template Updated 30/07/2021 also), a blood pressure of 91/71 respiratory rate 17, SpO2 100% and Glasgow Coma Score 15. It was documented that Christian ‘looks pale’. Christian was triaged using the Manchester Triage System as category 2. A plan was made for ongoing observations, an ECG, bloods and IV fluids. Only the observations and ECG were ticked as having been done. Christian was moved into the resuscitation area of the ED, together with his parents. He was in a wheelchair. The first set of observations were documented at 18:00. These recorded a respiratory rate of 25, SpO2 97 on air, temperature 35.9C, blood pressure 79/46, Alert on the AVPU scale. 9. 10. 11. 12. The NEWS score was 10. 13. It was documented that the observations should be continued at 30-minute intervals. 14. The first ECG was done at 18:07. 15. 16. A nurse was involved in care in the resuscitation room together with an ST3 Doctor with the latter recording a number of entries in the notes from circa 18:10 onwards when the assessment was undertaken. The presenting problem was documented as cough, raised temperature, palpitations. 17. The history included: Unwell since yesterday morning Felt palpitations while having lunch In the night developed cough, productive of white phlegm Had raised temperature and took paracetamol and ibuprofen Body ache and three episodes of vomiting Chest tightness but no pain SOB at times 18. It was also documented that there was no nasal discharge or blockage, no sore throat, no rashes or neck pain, no abdominal pain, and no sudden change Regulation 28 – After Inquest Document Template Updated 30/07/2021 in bowel habit. 19. Those observations were recorded as per the observations done at 18:00. In addition, Christian was documented as being dehydrated ++. The pulse was documented as regular with normal heart sounds and the chest was clear with no increase in respiratory effort. The abdomen was soft and non-tender. Christian was not delirious, the GCS was 15, and neurological examination was normal. 20. The working diagnosis was noted as ? sepsis ?chest infection ?viral. 21. The management plan was: ECG (this was done at 18:07 - described as sinus tachycardia). Bloods – VBG, cultures CXR Urinalysis (a dipstick of the urine to look for signs of infection etc). IV fluids Antibiotics TCI (meaning to come in) under medics if required. 22. The assessment was noted as completed at 18:35. 23. An x-ray was undertaken at circa 18:55 24. Normal saline 1L (an intravenous fluid) and co-amoxiclav 1.2g were prescribed at 18:30 and were documented as started/given at 19:00. 25. Further observations documented at 18:30 reported respiratory rate 23, SpO2 96% on air, temperature 35.6, BP 94/43, heart rate 143, alert. The NEWS score was 8. It was documented that 30-minute observations should continue. 26. At 19:00, cyclizine 50 mg (an anti-sickness drug) was prescribed and this was documented as being given at 19:20. 27. There was a change of shift at 19:00. 28. A nursing handover was recorded - 19:25. Regulation 28 – After Inquest Document Template Updated 30/07/2021 29. 30. 31. 32. 33. Multidisciplinary documentation at 19:35 reported that .. ‘pt looks pallor & presenting as acutely ill. BP↓ & tachycardic. Tx underway.’ At 19:50, it was documented ‘Struggling to get venous bloods’ and at 20:00 ‘Arterial bloods taken’. An arterial blood gas result recorded at 19:44 showed a pH 7.409, PaCO2 3.1kPa , PaO2 9.88 , HCO3 14.3 mmol/L , BE -7.9 , K+ 5.72 , lactate 5.6 mmol/L. Bloods were received at the haematology laboratory at 20:07 (taken at 19:50), and the clinical chemistry laboratory at 20:13. Observations documented at 20:00 respiratory rate 30, SpO2 100% on air, temperature 36.2, BP 83/?56, heart rate 141, alert, blood sugar 5.6 and a NEWS of 9. Nursing documentation at 20:00 stated ‘No change to pt [patient] condition’. 34. At around 20:15 it was documented that ‘mother called for help – pt agitated -? Peri-arrest then started agonal breathing.’ 35. Retrospective notes written at 20:30 by a medical registrar documented: Patient suddenly started gasping and not responding at around 20:00 ED team attended – no pulse Pads attached; polymorphic VT noted. CPR started, 150J shock given, CPR continued ROSC , lasted for few ? min Again lost pulse, CPR started ROSC obtained Magnesium infusion + amiodarone infusion started [MgSO4 2g (8 mmol) is documented as given at 20:20, amiodarone 300 mg is documented as given at 21:07] Decision to intubate made by ED Consultant Intubated under sedation Regulation 28 – After Inquest Document Template Updated 30/07/2021 36. Retrospective notes written at 20:30 by an ST6 EM documented that they attended a peri arrest buzzer and that the patient was in cardiac arrest and that CPR was in progress. The ED/ICU Consultant was leading. The ST6 EM managed the airway and intubated the trachea uneventfully. 37. Haematology results were reported at 20:22 – the only abnormality being a raised white cell count of 16.4 (monocytes 1.1, neutrophils 13.1). 38. A second ECG was done at 21:09. On it was documented ‘SR (sinus rhythm)’. 39. 40. 41. Clinical Chemistry results were reported at 21:08 and were phoned through to ED. A call from the lab was documented at 21:20: sodium 13, potassium. 6.5, creatinine 115 Other abnormalities on the clinical chemistry were, a raised lactate (4.7 mmol/L), raised urea (10.5 mmol/L), raised CRP (44 mg/L) and a slightly raised ALT (64 U/L). Of note the troponin T was raised at 118 ng/L. An ABG taken at 21:15 showed a severe mixed respiratory and metabolic acidosis (pH 6.97, PaCO2 8.52, BE -17.6, lactate 8.7) and a raised potassium (5.23). The PaO2 was 27 on 80% oxygen. 42. Christian had a urinary catheter inserted. 43. A second chest X-ray was done at ~ 20:48. 44. An ABG taken at 21:51 showed an ongoing severe lactic acidosis (pH 7.1, BE -4.2, lactate 10.3). The PaO2 was 14.56 on 21% oxygen. 45. A third ECG was done at 22:06 46. An ABG taken at 22:21 showed lactic acidosis (pH 7.05, - 16.3, lactate 11.2). The PaO2 was 12.43 on 21% oxygen. 47. Retrospective notes by the ED consultant at 23:35 documented: Responded to cry for help – parents in resus Patient had suddenly become unresponsive and started gasping Agonal respiratory effort HR 192 regular on monitor – palpable pulse Oxygen applied followed by resp arrest Regulation 28 – After Inquest Document Template Updated 30/07/2021 BVM and pads VF on monitor and no pulse Shock x 1 followed by CPR ROSC – tachy then VT with pulse followed by PEA arrest [pulseless electrical activity] CPR for less than one minute before signs of life. Patient moving arms HR 154 SVT SBP 111 GCS 4 (E1V1M2) . Minimal respiratory effort. I+V Hypotensive despite IV fluids (a vasoconstrictor drug that is used to raise the blood pressure – a total of 9.5 mg was given between 20:25 and 21:05). (2L) and metaraminol boluses Amiodarone and MgSO4 infusions (anti-arrhythmic drugs) (MgSO4 2g (8 is documented as given at 20:20, amiodarone 300 mg is mmol) documented as given at 21:07) Ceftriaxone given (? Meningoccal sepsis) 2g documented as given at 21:40] L femoral CVC placed. Noradrenaline infusion commenced. R femoral arterial line placed ICU consultant present. 48. 49. 50. Bedside echo by an ICU consultant and also another clinician showed septal wall akinesia. IVC filled. BP remained 80 systolic despite increased noradrenaline (1 g/kg/min). Hydrocortisone 100 mg documented as given at 21:00. Dobutamine 30 mL/hr commenced as started at 21:45. In addition, it was documented that terlipressin 0.5mg was given at 21:55 and that actrapid 10u/50 mL 50% glucose was given but no time was provided. 51. A further litre of normal saline was documented as being given at 21:10. 52. Worsening ABGs: 100 mL 8.4% NaHCO3 , 10 ml 10% calcium gluconate is Regulation 28 – After Inquest Document Template Updated 30/07/2021 timed as given at 21:25. 53. ECG ? Brugada 54. 55. A tertiary hospital Cardiology SpR was informed about possible salvage ECMO The systolic BP dropped to 60 mmHg and boluses of adrenaline (total of 400g given between 22:09 and 22:18) were given without response. An adrenaline infusion was started at 22:18 56. A calcium chloride infusion was started at 22:35 57. Observations at 22:25 recorded BP 50/31 and HR 108 58. The blood pressure remained low (systolic blood pressure < 50 and the lactate continued to increase (11.2 on ABG done at 22:21). 59. Observations at 22:45 recorded BP 68/40 and HR 135. 60. 61. 62. 63. Christian was increasingly mottled, worsening gas exchange – likely due to poor perfusion. He was mainly unsedated throughout and no further muscle relaxants since RSI. A call was made to a transplant fellow at a tertiary hospital – the response was, ‘unsure if can help, will speak to consultant’ There was a discussion with the tertiary hospital ICU consultant who said, ‘No one is entirely sure what the aetiology is. It is therefore very difficult to know what can be reversed by ECMO, and it is unlikely to be tolerated. Given the prolonged period of hypotension and lack of reversible cause which we can further improve, there is nothing more that can be done’. 64. This was discussed with the family, and it was agreed to stop active treatment and allow him to die which was documented at 23:45. 65. An independent expert report opined that when Christian was first assessed in ED, the symptoms were non-specific (palpitations, chest tightness, cough, aching, vomiting) but there were several concerning observations indicating severe illness. These included: Tachycardia (fast heart rate) with the lowest rate being 132 and rates of up to 240 documented (a rate that is non-physiological and Regulation 28 – After Inquest Document Template Updated 30/07/2021 indicative of an arrhythmia – abnormal heart rhythm). Hypotension (low blood pressure) Tachypnoea (fast respiratory rate) Hypothermia (low temperature) High NEWS score (8-10) Looking pale [documented by triage nurse and resus practitioner] Dehydrated ++ was documented at the first medical review. 66. 67. The expert felt that it was appropriate that Christian was moved into the resuscitation area of the ED where he could be continuously monitored and where there is a high staff/patient ratio. The NEWS score of 10 required the triggering of a clinical response (as documented in the Emergency Department Majors proforma): The medical review at 18:10 was reasonably comprehensive but missed several key points including: There was no reference to the heart rate of 240 that was documented in the Doctors notes. It is likely that these arrhythmias were ventricular tachycardia. It was not documented whether Christian had been passing urine normally. The capillary refill time and the strength of the peripheral pulses were not documented, a short capillary refill time and bounding pulse may have more in keeping with sepsis, and a slow capillary refill time and weak pulse would have been more in keeping with a low cardiac output state from either hypovolaemia (reduced blood volume) or reduced cardiac contractility. The jugular venous pressure (JVP) was not documented (a sign of central venous filling pressures and cardiac function). The ECG was documented as sinus tachycardia. I accepted the evidence of a number of experts that this was not a normal ECG and that there were other non-specific abnormalities. Regulation 28 – After Inquest Document Template Updated 30/07/2021 It was considered that the non-specific abnormalities could be seen in conditions such as hyperkalaemia [high potassium levels] and cardiac dilatation. A chest X-ray was requested but the results of this were not documented. In the opinion of the expert ICU consultant, the CXR showed some soft ground glass opacification (GGO), mild upper lobe diversion (increased blood flow to the upper parts of the lung because of increased left sided heart pressures), and some fluid in the horizontal fissure (fluid outside of the lung sitting between the upper and middle lobes) – all these are consistent with heart failure, but they are not specific. In his opinion, these were quite subtle signs and could easily be missed. A retrospective review by a specialist forensic radiologist was clear on the presence of cardiomegaly on the imaging. Chest sepsis can cause GGO but in the opinion of the ICU expert there was no clear evidence of chest sepsis on the CXR. The ICU expert did see evidence of some mild pleural fluid in the horizontal fissure. 68. 69. The medical diagnosis was of possible sepsis. I found that it was appropriate to have this high on the list of differential diagnoses as although the presentation was not classic, sepsis can present in many ways and a high index of suspicion is required. However, I did find that it should have been immediately recognised that Christian was in a shocked state from his tachycardia, hypotension, and poor perfusion. 70. When a patient presents with undifferentiated shock (unclear cause), I concurred with the expert evidence, that it is important to immediately initiate therapy whilst rapidly trying to identify the aetiology so that definitive therapy can be administered. 71. I again agreed that it should be expected that any clinician would rapidly treat and investigate the cause of the shock and to regularly reassess to determine the response to treatment and to review the results of investigations. This would need discussion with Senior staff. There was a discussion between the ST3 and the ED consultant but the information exchange did not lead to a consultant face to face assessment of Christian prior to his arrest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 72. The differential diagnosis was not broadened prior to the cardiac arrest. 73. 74. I agreed that it could be expected that a clinician should have recognised that Christian was acutely unwell. As part of the rapid assessment of the aetiology of the shock I concurred with the view that a low cardiac output state ought to have been considered. Because of the probable tachyarrhythmias, the abnormal ECG, the tachycardia and the low blood pressure, cardiac pathology should have been considered. Several entries in the records pointed to Christian being in a ‘shut down’ state (poor peripheral perfusion) – this was documented by the triage nurse (‘looks pale’), the ST3 ED doctor (’dehydrated ++) and the resuscitation room practitioner (‘pallor’, ‘struggling to get venous bloods’). This should have further increased the suspicion of a low cardiac output state. 75. Focused echocardiography was not undertaken and would be a key diagnostic tool, when it is available. It could have answered several simple questions such as: Is the heart dilated? Is the heart contracting normally? Is the heart/circulation well filled? Is there a pericardial effusion (fluid in the sac around the heart) and if so, is this compromising the heart? 76. 77. 78. An ICU expert was of the opinion that focused echocardiogram should have been done and would likely have shown some abnormalities. An expert Cardiologist also emphasized the importance of this diagnostic tool. It was stated that in sepsis, especially after appropriate fluid challenges, the heart is usually well filled and pumping vigorously on echocardiogram. In cardiogenic shock, the heart function is impaired on echocardiogram and depending on the cause, the chambers may be dilated. The ICU expert indicated that a possible diagnosis of sepsis should have triggered a bundle of assessments/interventions such as the Sepsis 6 bundle. The Sepsis 6 Bundle/Pathway is a series of simple interventions that has been widely used in the NHS since 2007 – it aims to reduce the mortality from sepsis. 79. By the time Christian was in the resuscitation room, he had three ‘Red Flag’ triggers on the Sepsis Screening tool, any one of which should have triggered Regulation 28 – After Inquest Document Template Updated 30/07/2021 the Sepsis 6 pathway. The Sepsis 6 pathway includes the following interventions, all of which should be completed within one hour: Administer oxygen Take blood cultures, think source control [where is the infection arising from and can the source be controlled]. Chest X-ray and urinalysis. Give IV antibiotics Give IV fluids – if hypotensive or lactate >2 then 500 mL stat, which may be repeated if clinically indicated Check serial lactates – if lactate > 4 mmol/L then call critical care and recheck after fluid challenges Measure urine output and commence fluid balance chart If the above interventions do not work or the patient is clearly critically ill, then immediate referral to critical care is indicated. 80. The chest X-ray showed some abnormalities consistent with heart failure; however, there was no handwritten documentation of the time that it was reviewed or what it showed. 81. boluses Intravenous fluids were commenced but these were not given as rapid and targeted against response - Christian remained hypotensive and tachycardic despite the fluid administration. 82. Apart from the blood cultures, bloods were not taken until 19:44. 83. I found that that the urgency of the situation was under-appreciated by the treating team. An expert indicated that it is very well recognised that unwell, and normally fit, children/young adults often look quite well until the point at which they rapidly decompensate. In the experts opinion, the fact that Christian was sitting up and talking resulted in a false sense of security and an under-appreciation of the physiological abnormalities on the part of some of those involved. 84. The expert also opined that there was a clear delay in getting the first blood gas. A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given, and a venous blood gas should have been taken from this. This would likely have shown a raised lactate and potassium (as the Regulation 28 – After Inquest Document Template Updated 30/07/2021 ABG did at 19:44) – both of which would have impacted on management and should have further highlighted the severity of the situation. 85. 86. I found that if there was difficulty in getting bloods, then this needed to be resolved by deployment of appropriate measures to expedite this. Earlier correction of the high potassium, recognised, may possibly have reduced the chance of further arrythmias. if it had been measured and 87. Cyclizine was given as an antiemetic at circa 19:20. SUBSEQUENT CARE DURING AND AFTER THE CARDIAC ARREST 88. 89. 90. 91. I share the views expressed in written reports and oral evidence that the care given during the resuscitation was generally of a high standard and everything possible was done to restore a spontaneous circulation and to protect organs from damage. Once return of spontaneous circulation (ROSC) had been achieved then it was appropriate to intubate and commence mechanical ventilation. The viewing and findings of the chest X-ray done at 20:48 were not documented. I was of the view that the clinical situation after ROSC was extremely challenging with ongoing shock and hypotension despite multiple interventions. There was significant post cardiac arrest ‘cardiac stunning’ in the context of an already dilated and weak heart from the pre-existing cardiomyopathy. 92. The evidence of fluid management after arrest was hampered by a lack of clarity over timings and the nature of retrospective entries. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN ARE: POINT A - RE: CARDIOGENIC SHOCK CS) TO: i. Department of Health and Social Care Regulation 28 – After Inquest Document Template Updated 30/07/2021 ii. iii. Cambridgeshire and Peterborough ICB NWAFT I have a concern over recommendations set out below. funding availability and implementation of the key The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK. The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival. It was stated that CS is a commonly encountered but often under recognised clinical challenge with high mortality. This document outlined several recommendations as part of a systems approach to improving patient survival and experience. These included but were not limited to: A. Increase awareness among healthcare staff that any deteriorating patient with an elevated National Early Warning Score (NEWS) 2 and evidence of hypoperfusion should prompt consideration of CS as a potential cause. Echocardiography or focused cardiac ultrasound FoCUS and electrocardiogram should follow urgently. B. Improve access to echocardiography out of hours (including FoCUS with expert review) to support/exclude the diagnosis of CS or other cardiac pathologies C. Adopt SCAI staging as the standardised descriptor of CS to facilitate triage, communication and expediency of discussion with a CS centre. D. Establish CS centres as part of regional CS networks to bring together the most critically ill patients with the right clinical expertise E. Ensure equity of access to CS expertise and care, including short-term MCS, through the design of CS networks and distribution of CS centres F. Develop clear pathways of care and protocols for CSS care within networks to complement existing acute cardiac care pathways, including 24/7 access to CS MDT's and transfer to CS centres G. Developed network protocols for patient selection for short- term MCS H. Define a minimum CS data set and collect this data, including through existing national audits, encompassing the entire patient pathway Regulation 28 – After Inquest Document Template Updated 30/07/2021 I. Prioritise high-quality research in CS to address important areas of including a patient selection for short-term MCS and cost- uncertainty, effectiveness of improved care pathways. The report recognised that the National Cardiac Pathway Improvement Programme (CPIP) represented an opportunity to embed many of these recommendations, to potentially transform outcomes in CS patients, and CPIP leaders nationally and regionally should work with stakeholders and CS experts to implement them. POINT B - RE: ECHOCARDIOGRAPHY TO: i. ii. iii. iv. v. Department of Health and Social Care Royal College of Emergency Medicine The Faculty of Intensive Care Medicine NWAFT Cambridgeshire and Peterborough ICB Christian had not had an echocardiogram prior to his arrest. This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state. Whilst the paper below focussed on critical care, there is a concern on the use of echocardiography in EDs and also within critical care departments given the findings that emerged from this research. The paper by Luke Flower (et al) : The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study ( Intensive Care Medicine :2024) emphasised that echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 ( 54%) cases, with a change in management in 270 (50%) and a reduction in of diagnostic uncertainty in in 120 ( 20%) of patients. The conclusion was that urgent echocardiography is not routinely used in the assessment of critically ill patients with shock in the UK and Crown Dependencies, despite international guidance. The study suggests that echocardiography may alter management and improve diagnostic certainty in patients with undifferentiated shock. Future work should explore barriers to the expansion of echocardiography provision within critical care to permit improved equity of care amongst patients presenting with shock. The study was on behalf of NEAT ECHO collaborators and in association with the British Society of Echocardiography (BSE). The BSE highlighted an additional study finding that it was disappointing to read that only 25% of echocardiograms adhered to national storage guidance. This discrepancy was said in part to relate to poor underlying infrastructure for electronic image storage and transfer. The BSE commented that this was a reminder that delivering a high-quality echo service is not Regulation 28 – After Inquest Document Template Updated 30/07/2021 only reliant on having an echo machine, but also a variety of additional background information technology components that the BSE would recommend as inconceivable to be absent from a modern CT or MRI imaging service. POINT C - FLUID MANAGEMENT To: i. ii. NWAFT Cambridgeshire and Peterborough ICB (CPICB) Intravenous fluids were commenced but these were not targeted against response. Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also. Another example of this is seen in a coronial investigation into the death of LM within the trust under reference 01976-2023. An independent expert flagged an issue on fluid management in that matter and the Trust SI report also found that the effects of Hartman’s solution was not evaluated, and no further fluids were given. Additionally, adherence to policy on completion of fluid balance charts and the understanding and need for acting on flags is a matter of concern. It is not clear if the trust and CPICB has identified this as a recurring theme in audits/deep dive reviews. POINT D -TEAM INTERACTIONS To: i. NWAFT A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team. The under appreciation by some staff of how critically unwell Christian was raises an issue on exchanges of information and team culture. An example is the entry … ‘TCI medics, if required’ … and so there was no expression of the need for urgent review by the medical team by the key clinician involved in ED care. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The cases of CR under case ref :03638-2019 and SO under case ref: 00133-2023 are further examples on issues of team interactions. A final example is seen again in the death of LM (see ref earlier). The SI of the trust found that case management and plans should be carried out in a timely manner, (particularly administration of antibiotics, blood test requests and specialty team assessment following referral from the ED). It was found that the deceased had not been seen by the medical team after referral to them and before a cardiac arrest. POINT E – RADIOLOGY WITHIN NWAFT TO: i. NWAFT Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken. There have also been a number of instances in our coroner investigations where there is an issue surrounding radiology. POINT F -RADIOLOGY NATIONALLY TO: i. ii. The Royal College of Radiology Department of Health and Social Care I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool. Further, there seems an almost two-tier system – that available in Tertiary hospitals and that available in district general hospitals. POINT G – BLOOD GASES/ ELEVATED LACTATE TO: i. NWAFT There was a delay in getting the first blood gas. A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this. This would likely have shown a raised lactate and potassium (as Regulation 28 – After Inquest Document Template Updated 30/07/2021 the ABG did at 19:44) – both of which would have impacted on management and would have further highlighted the severity of the situation. The ABG at 19:44 was consistent with a compensated lactic acidosis and hyperkalaemia. In the case of CR (see earlier ref). A blood gas requested by an anaesthetist was not done. A further example is seen in the coronial investigation into the death of SO (see earlier ref) where an expert concluded that lactate was not measured until 02:30 on 30.12.2022 and it was 5.1. mmol/L – recognition of its elevation would likely have prompted earlier senior review, CT imaging and review by critical care. Again, in the death of LM (see earlier ref). An independent expert report has raised a number of issues on clinical management in that matter. Specifically, the lactate was 9.18 from a VBG timed at 05:10 on 28/7/23 and the trust itself in an SI report concluded that there was no escalation. The death of Christian and these further examples raise a concern. POINT H - CRITICAL CARE TO: i. ii. NWAFT Cambridgeshire and Peterborough ICB (CPICB) The CQC reports in 2018 and 2019 highlighted issues surrounding critical care. The coronial investigation into the death at Hinchingbrooke Hospital of CR (see earlier ref) led to an independent expert’s report being commissioned that flagged suboptimal care. There was a finding of neglect (a gross failure of basic medical care) at the final inquest hearing. There would not appear to have been a Trust SI report in that matter. There are concerns about resources and training within the trust for this specialty. Furthermore, there is a concern as to whether the trust has had/acted upon any internal/ external review of the CCU at Hinchingbrooke Hospital. POINT I - DIFFERENTIAL DIAGNOSIS TO: i. NWAFT A recurring theme is lack of a differential diagnosis which raises concerns about Regulation 28 – After Inquest Document Template Updated 30/07/2021 training. POINT J - SEPSIS PATHWAY TO: i. ii. NWAFT Cambridgeshire and Peterborough ICB C&P ICB This is again another theme and accordingly raises a concern about training and auditing. Within the context of the death of LM (see earlier case ref), there was inter alia, a delay in the administration of antibiotics and cultures were not taken. Again, the case of CR (see earlier case ref) highlighted deficiencies on this topic. POINT K- ANTIEMETIC MEDICATION To: i. ii. iii. NWAFT Royal College of Emergency Medicine Department of Health and Social Care It will be seen from the circumstances set out earlier that cyclizine was administered at 19:20. Christian arrested at shortly after 20:00. This drug is known to cause adverse cardiovascular effects – tachycardia, arrythmias, hypertension and hypotension. Therefore, it is at least possible, given the subsequent physiological collapse of Christian that this medication possibly had some adverse effect on a background of an underlying arrhythmogenic cardiomyopathy. I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also. This was highlighted in the paper: Ventricular Fibrillation Arrest Triggered by Antemetics Revealing an Underlying Long QT Syndrome in a Young Woman. Cureus 16(7). July 2024. It was emphasised that with antiemetic prescriptions being a common practice, it is vital to educate about their side effects, such as prolongation on QT. Exercising future caution before using these medications will help mitigate the risk of such adverse events. While emergency departments are already so busy, routine ECGs could help Regulation 28 – After Inquest Document Template Updated 30/07/2021 prevent such disasters from happening. It is also essential to ensure that doctors are equipped with the necessary skills and experience for early recognition of such a phenomenon. A multilayered approach focusing on clinical education from undergraduate to postgraduate levels alongside multidisciplinary collaboration can help ensure the delivery of high-quality care going forward. POINT L – ECG ANALYSIS TO: i. ii. iii. NWAFT Department of Health and Social Care Royal College of Emergency Medicine Some Issues emerged in evidence on the interpretation of the ECG at 18:10. It has been pointed out in a study by Abdalla and Khanra: Electrocardiography interpretation proficiency among medical doctors of different grades in the UK. Cureus 2022 that analysing the ECG interpretation proficiency among medical doctors showed low levels of clinician confidence in interpreting ECGs. The paper in point K above also stated that this highlighted a deficiency that needs urgent attention due to the importance of the investigation, especially since an abnormal ECG can lead to potentially life-threatening consequences. Continued education was said to be paramount to ensure safe management of patients with LQTS. This again raises concerns. POINT M -RECORD KEEPING TO: i. NWAFT There was a lack of recorded evidence on key aspects of Christians care. This was flagged also in CQC inspections and within the context of this investigation there was no record of measurement of jugular venous pressure or capillary refill time and no record of reviews of X-Rays. Again, in the case of LM (see case ref earlier), the trust SI report found nothing in the notes about staff action with the patient at a critical timepoint. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Reference to this also arose in the case of CR (see case ref earlier) where the expert flagged inadequate documentation. POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS TO: i. NWAFT Family evidence was heard that there appeared to be deactivation of the monitor alarm at a particular point in time and when Christian arrested, they had to call staff members for help. The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time. This hampered consideration of data in the death that required detailed review and this is a concern. This was a case where a retention of the data, given the circumstances, would have greatly assisted understanding physiological changes at key points and would assist lessons to be learned to mitigate risk of other deaths. POINT O – LEARNING FROM HSSIB REPORTS TO: i. NWAFT I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training. POINT P - PATIENT SAFETY IN SOME TRUST AREAS TO: i. ii. NWAFT Cambridgeshire and Peterborough ICB The CQC reports in 2018 and 2019 indicated there was a requirement improvement when inspecting whether services were safe. for There have now been a number of independent expert reviews in coronial investigations which have highlighted sub optimal clinical care in fact specific Regulation 28 – After Inquest Document Template Updated 30/07/2021 scenarios. NWAFT cases and issues arising, seem to exceed the number of cases referred from tertiary hospitals in this coronial area. This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS TO: i. Department of Digital, Culture, Media and Sport. The paper by Teresina Vesella (et al) in Br J Sports Med 2019 :The Italian evaluation programme : diagnostic yield, rate of disqualification and cost analysis pointed out that Italian Law mandated that every athlete must undergo annual preparticipation evaluation ( PPE) to identify cardiovascular diseases that pose a risk of sudden death during sport and other conditions that may threaten the athlete’s health. The conclusion was that PPE according to the Italian model identified a range of diseases in 2.0 % of apparently healthy athletes at an average cost of 79 euros per athlete. The paper by H.MacLachlan (et al) in the Journal of Science and Medicine in Sport in 2022 concluded that an electrocardiogram-based national screening programme identified a major cardiac condition in 0.3 % of the cohort (in elite cricketers). I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic. Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms. This is despite the outstanding work of CRY. POINT R – CHILD DEATH OVERVIEW PANEL REVIEW TO: i. NORTHAMPTONSHIRE SAFEGUARDING CHILDREN PARTNERSHIP the death occurred in Cambridgeshire, the Whilst Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision. This is a concern given the is understood that it Regulation 28 – After Inquest Document Template Updated 30/07/2021 scale of the coronial investigation that has revealed a number of significant issues on clinical management. POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW TO: i. NWAFT It is unclear whether any NWAFT paediatric review (it is noted that Christian was treated as an adult patient and the paediatric team were not involved in his acute care) found any issues from a learning perspective given the matters analysed at length within the coronial investigation. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02 June 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION 1. 2. 3. Association for Cardiothoracic Anaesthesia and Critical care 4. British Association of Critical Care Nurses 5. British Cardiovascular Society 6. British Cardiovascular Intervention Society 7. British Society of Echocardiography 8. British Society for Heart Failure 9. Intensive Care Society Regulation 28 – After Inquest Document Template Updated 30/07/2021 10. Resuscitation Council (UK) 11. Royal College of Nursing 12. Society for Acute Medicine 13. Society for Cardiothoracic Surgery in Great Britain and Ireland 14. Scottish Intensive Care Society 15. The College of Paramedics 16. The Northern Ireland Intensive Care Society 17. Care Quality Commission 18. HSSIB 19. England Boxing 20. 21. 22. I am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response. 9 Dated: 07/04/2025 David HEMING Regulation 28 – After Inquest Document Template Updated 30/07/2021 Senior Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
8 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Our ref:
Your ref:
For the attention of
David Heming
Senior Coroner
Cambridgeshire & Peterborough Coronial Service
Lawrence Court
Princes Street
Huntingdon
PE29 3PA
Sent via email to:
cc:
Dear Mr Heming
NHS Cambridgeshire & Peterborough
Gemini House
Bartholomew’s Way
Ely
Cambridgeshire
CB7 4EA
Tele 03300 571030
Date: 28th May 2025
Re: Christian James Gabriel HOBBS - Date of death 26 December 2017
Thank you for your Regulation 28 Prevention of Future Deaths Report regarding Christian James Gabriel
Hobbs that the ICB received on 8 April 2025. We note the content and the points raised for an ICB
response.
We wish to express our sincere condolences to Christian’s family and friends. We have taken this matter
extremely seriously.
The matters of concern that you have raised within your report relevant to NHS Cambridgeshire and
Peterborough Integrated Care Board (CPICB) are listed below together with the actions that we have or
will be undertaking to prevent future deaths. We have used lettering for each point as per the Prevention of
Future Deaths Report.
A. Cardiogenic Shock
The Prevention of Future Death Report noted that concerns were identified over funding availability
and implementation of the key recommendations set out within the document ‘Shock to Survival’
• CPICB recognises that while the recommendations within the Shock to Survival document have
not been nationally mandated, they represent best practice and are integral to delivering high-
quality care within acute NHS hospital settings. The ICB have implemented an improved
contractual process where all providers have a Clinical Review Quality Meeting each month,
alongside a Technical Information Finance Meeting. The ICB will seek assurance of compliance
with the Shock to Survival recommendations through Clinical Quality Review Meetings with
North West Anglia NHS Foundation Trust and other providers in the Cambridgeshire and
Peterborough Integrated Care System that care for similar patient groups.
1
This process will be undertaken through Clinical Quality Review Meetings and is expected to be
completed by 30 June 2025.
B. Echocardiography
The Prevention of Future Death Report noted that Christian had not had a transthoracic
echocardiogram or focused echocardiography prior to his arrest and that this was a concerning
feature of his care in the Emergency Department, given he was critically unwell and in a shocked
state.
• CPICB will work with North West Anglia NHS Foundation Trust and other providers caring for
similar patient groups to gain assurance that mechanisms are in place to ensure critically ill
patients have 24/7 access to either transthoracic echocardiography or focused
echocardiography. This process will be undertaken through Clinical Quality Review Meetings
and is expected to be completed by 30 June 2025.
C. Fluid Management
The Prevention of Future Deaths Report noted that it was unclear if audits and deep dive reviews
have identified the completion of fluid balance charts and the understanding of the need for acting
on flags as a recurring theme.
• The ICB implemented a weekly Serious Incident Closure Assurance Panel in 2021 with the
purpose of having oversight of all serious incidents reported by providers across
Cambridgeshire and Peterborough Integrated Care System. This process was superseded by
the nationally mandated Patient Safety Incident Response Framework (PSIRF), which changed
the model for incident reporting and response.
• Under PSIRF, the ICB now only maintains direct oversight of Patient Safety Incident
Investigations (PSIIs). If providers choose to use alternative PSIRF tools (e.g., after action
reviews, thematic analysis), the ICB is informed of these only through themes and trends
reported in quarterly submissions. Additionally, the ICB has representation at the weekly
provider Patient Safety Meetings, where all incidents are reviewed.
• From analysis of patient safety data since 2017, fluid management has not emerged as a
recurrent theme within North West Anglia NHS Foundation Trust (NWAFT). Furthermore, fluid
balance monitoring forms part of the Trust’s ward accreditation programme, which reviews
wards against a range of national care standards. It is also embedded within the Trust’s core
matron audit programme, ensuring ongoing oversight and quality improvement. The Trust
continues to hold the responsibility to ensure that it will share any emerging themes or risks to
the ICB in the monthly Integrated Quality Report.
H. Critical Care
The Prevention of Future Deaths Report noted that there were concerns in relation to resources
and training for this speciality and whether the Trust had acted upon any reviews of the Critical
Care Unit at Hinchingbrooke Hospital. The ICB have implemented an improved contractual process
2
where all providers have a Clinical Review Quality Meeting each month, alongside a Technical
Information Finance Meeting.
All Trusts share their key risks, emerging issues, mitigations and data with the ICB in report format
prior to these meetings. This process provides the ICB with oversight and assurance.
• The East of England Critical Care Network undertook a review of Critical Care Services at
Hinchingbrooke Hospital in September 2023, with a follow-up visit in June 2024. This is part of
the East of England Adult Critical Care Operational Delivery Network’s rolling programme to
quality assure care provision across the region.
The CPICB Quality Team were invited to join the critical care review by the Critical Care
Network. Following this visit the Critical Care Network led upon review of the action plans and
gaining assurance that the recommendations had been acted upon.
J. Sepsis Pathway
The Prevention of Future Deaths Report noted that there were concerns about training and
auditing of the sepsis pathway
• North West Anglia NHS Foundation Trust includes sepsis data as part of its monthly Integrated
Quality Report to CPICB. This data is reviewed regularly and does not currently flag as an
outlier when compared to regional or national benchmarks. Within this report, providers also
highlight any emerging risks and issues. To date, sepsis has not been raised to CPICB as a
concern. Based on current data and provider reports, CPICB assesses the Trust’s approach to
sepsis management as adequate. We will continue to monitor for any changes in performance
or risk indicators.
P. Patient Safety in some Trust areas
The Prevention of Future Death Report noted that it is unclear as to whether there has been a
deep dive or audit/review to look at patterns/trends rather than simply looking at raw overall
mortality data.
• North West Anglia NHS Foundation Trust’s Quality Assurance Committee holds a monthly
meeting, alternating between surveillance and deep dives on identified themes. This is
attended by representatives from CPICB. The Trust’s Patient Safety Incident Response
Framework (PSIRF) plan outlines detailed quality improvement initiatives, and we are working
with the Trust to gain assurance that progress is being made in the areas defined.
• The Quality Team recognises the forthcoming Trust’s implementation of a nationally validated
software system called, GENOME. This system will support improved patient safety
surveillance, including ward-to-board visibility of safety themes and triangulated data.
CPICB will have access to GENOME dashboards, which will enhance our ability to monitor
assurance, track progress against quality priorities, and identify areas requiring escalation or
support.
3
We trust the actions taken by us address the concerns raised and we will continue to work with our
partners to continue improvements. Should you seek any further clarification, please do not
hesitate to contact us.
Yours sincerely
Chief Medical Officer
NHS Cambridgeshire and Peterborough ICB.
MA FRCP MRCGP FFPH DTM&H
4
Minister for Sport, Media, Civil Society and Youth Department for Culture, Media and Sport 1st Floor 100 Parliament Street London SW1A 2BQ E: www.gov.uk/dcms 6 May 2025 Our Ref: Mr David Heming Senior Coroner, Cambridgeshire and Peterborough Dear Mr Heming, Thank you for your correspondence of 7 April and for enclosing the Regulation 28 Report in relation to the inquest for the death of Mr Christian Hobbs. I am responding as the Minister for Sport, Media, Civil Society and Youth, and I would like to pass on my sincere condolences to the family and friends of Mr Hobbs for their loss. This is a tragic incident, and it is right we fully consider all lessons that can be learnt. The safety and wellbeing of everyone participating in sport is absolutely paramount, and individual sports should do everything they can to prioritise participants’ wellbeing. This is something I continue to push as the Minister for Sport. Your report states 2 aspects in relation to the Department for Culture, Media and Sport that I have considered below. With regard to funding, while I would be happy to raise the issue of cardiac screening with England Boxing, the department is not able to provide additional funding. England Boxing, the national governing body for community boxing in England, which is independent of the Government, is responsible for assessing and managing its funding requirements. England Boxing receives some of its income in the form of a grant from Sport England, the Government’s arm’s-length body for grassroots sport, but also receives income through other grants, fees and donations. I believe this gives them the avenues to explore any additional funding needed. In terms of parental awareness of sudden cardiac death, I fully agree this is an important issue. Through Sport England, we have supported Cardiac Risk in the Young’s excellent work in seeking to increase awareness, for example, through Sport England’s site for clubs and community organisations, Buddle. More generally, Sport England signposts to and share case studies from the Joe Humphries Memorial Trust, British Heart Foundation and UK Coaching’s online learning. Of course, there is always more to do in this area to ensure that young people are able to take part in sport safely. I will continue to work with sports to ensure that tragic events such as this can help us strengthen processes for the future. Yours sincerely, Minister for Sport, Media, Civil Society and Youth
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 16th October 2025 HM Coroner David Heming Coroner’s Service, Lawrence Court, Princes Street, Huntingdon, PE29 3PA Dear Mr Heming, Thank you for the Regulation 28 report of 7th April 2025 sent to the Department of Health and Social Care about the death of Christian James Gabriel Hobbs. I am replying as the Minister with responsibility for workforce. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Hobbs death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. As set out within the report, I will specifically be responding the points addressed to the Department, namely Points A, B, F, K, and L. In preparing this response, my officials have made enquiries with NHS England (NHSE) to ensure we adequately address your concerns. There is currently no national clinical commissioning policy for Cardiogenic Shock. NHSE, via the Cardiac Services Clinical Reference Group (CRG), has received two clinical commissioning policy proposals relating to cardiogenic shock for consideration. The CRG are aware of the cardiogenic shock network that has been developed in London and the work of the British Cardiovascular Intervention Society who are developing a working group to improve management and outcomes of cardiogenic shock provision across the UK. NICE’s Interventional Procedures Programme is looking at Insertion of a catheter-based intravascular microaxial flow pump for cardiogenic shock (IP2042). We understand that the expert working group is currently being established. NHSE and the British Heart Foundation co-funded a sudden cardiac death pilot. This was led by the NHSE Genomics team who are considering whether they can support any lines to aid the broader response. NHSE commissions the NHS Genomic Medicine Service (GMS) in England. Genomic testing in the NHS in England is provided through the NHS GMS and delivered by a national genomic testing network of seven NHS Genomic Laboratory Hubs (GLHs). The NHS GLHs deliver testing as directed by the National Genomic Test Directory (the Test Directory), which includes tests for over 7000 rare diseases with an associated genetic cause and over 200 cancer clinical indications, including both whole genome sequencing (WGS) and non-WGS testing. The Test Directory sets out the eligibility criteria for patients to access testing as well as the genomic targets to be tested and the method that should be used. A key part of the NHS GMS infrastructure is seven NHS GMS Alliances which play an important role in supporting the strategic systematic embedding of genomic medicine in end- to-end clinical pathways and clinical specialities, as well as raising awareness among clinicians and the public of the genomic testing available through the NHS. NHSE has previously funded the NHS GMS Alliances to deliver a number of transformations project, including one working with Inherited Cardiac Conditions (ICC) services, the British Heart Foundation and the Chief Coroner in England and Wales to establish: • consistent pathology referral practice for sudden unexplained deaths including use of expert pathology; • routine tissue retention for histopathology and DNA extraction in suitable SUD cases; • coronial and NHS communication pathways for referrals of families for genetic testing and clinical evaluation; • mechanisms for standardised post-mortem genetic testing and reporting via NHS Genomic Laboratory Hubs; • develop and disseminate nationally applicable best practice pathways for NHS adoption; and • ensure the engagement and input of patient and support groups with an interest in inherited cardiac disorders This approach has demonstrated the significant impact of partnerships in identifying family members with inherited cardiac conditions through a genomics-first approach to sudden cardiac death diagnoses. Data continues to be collected throughout 2025 to further evaluate and refine the programme. On points F, K, and L, where you raise issues of workforce levels and training, individual NHS Trusts and other employers are responsible for ensuring that staff are, and remain, competent and capable in their area of practice. We understand and appreciate the findings that adverse effects of antiemetics, namely cardiovascular effects may have had an impact. Universities are responsible for setting their own medical curricula, which must meet GMC standards. Postgraduate curricula are set by Medical Royal Colleges and are approved by the GMC. Whilst not all curricula may necessarily highlight a specific condition, they all emphasise the skills and approaches a doctor must develop to ensure accurate and timely diagnoses and treatment plans for their patients, including recognising and managing adverse reactions to prescribed drugs. I would further expect NHS Trusts and other relevant organisations to ensure that their protocols are appropriate in the wake of the death of Master Hobbs. In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan later this year. This will ensure the NHS has the right people in the right places to deliver the best care for patients. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
Mr David Heming Senior Coroner for Cambridgeshire and Peterborough VIA EMAIL 02 June 2025 Dear Mr Heming, Re: Regulation 28 Report to Prevent Future Death – Mr Christian Hobbs On behalf of the Faculty of Intensive Care Medicine, we firstly wish to express our sincere condolences following the death of Christian Hobbs. You have asked that the Faculty respond to concerns regarding the availability and use of echocardiography, and the storage of images following echocardiographic investigations. Historically, echocardiography was a skill almost exclusively reserved to cardiologists, cardiac physiologists and trained sonographers. However, in recent years, it has become increasingly common for practitioners in acute specialties (such as emergency medicine, acute medicine, and intensive care medicine) to have adopted the use of focused and limited echocardiographic examination to guide patient assessment. Cardiology services continue to provide more detailed and thorough echocardiography, enabled by higher levels of training, experience and expertise. Skills in focused, limited echocardiography is a rapidly growing area of intensive care medicine practice. The most recent curriculum for doctors training in intensive care medicine was implemented in 2021. As with all postgraduate medical training curricula it meets, and is informed by, the requirements mandated by the General Medical Council (GMC). One requirement is that a specific course or accreditation cannot be specified. Instead, the GMC has asked that training curricula are modelled to describe a number of high-level capabilities (so called ‘High Level Learning Outcomes, or HiLLOs). The curriculum for intensive care medicine contains fourteen HiLLOs. The use of focused echocardiography is covered in HiLLO 6: Intensive Care Medicine specialists will have the knowledge and skills to initiate, request and interpret appropriate investigations and advanced monitoring techniques, to aid the diagnosis and management of patients with organ systems failure. They will be able to provide and manage the subsequent advanced organ system support therapies. This will include both pharmacological and mechanical interventions. In response to evolving medical practice and guidance, the Faculty is currently undertaking a review of the HiLLO descriptors. As part of this process, consideration is already being given to providing further clarity around any requirement for specific training and skills in echocardiography. These discussions are ongoing, and any changes must ultimately be acceptable to the GMC. Together with the Intensive Care Society, the Faculty publishes the Guideline for the Provision of Intensive Care Services (GPICS). Over the last decade, GPICS has become the definitive reference for planning, commissioning and delivery of adult intensive care services in the UK. GPICS version 3 is currently at the consultation stage. In the chapter of GPICS version 3 titled ‘Cardiovascular Support’, it is noted that: “Whilst current guidelines recommend that hospitals who admit acute cardiology patients have access to echocardiography 24/7, this may not be universally available. Intensive care physicians have an important role in improving access to echocardiography out-of-hours to support / exclude the diagnosis of cardiac pathologies. This will facilitate appropriate triage. The sickest patients need to undergo emergent echocardiography by someone trained to British Society of Echocardiography (BSE) level 1 standard or higher.” By inclusion of this statement, the Faculty aims to demonstrate support for the reliable provision of emergent echocardiography across all UK hospitals, and we remain committed to working with the other hospital providers of echocardiography services to achieve this essential safety goal. We also share your concerns about the lack of infrastructure for storing ultrasound images. While the investment required is significant, image storage is vital for clinical management, education, and quality assurance. The GPICS version 3 chapter titled ‘Intensive Care Ultrasound’ (which is co-authored by three contributors to the Flower et al paper cited in the PFD report), contains as a minimum standard for all ICUs in the UK that: “ICUs must have the facility to store clinical and point-of-care ultrasound images in an appropriate picture archiving and communication system, so they form part of the clinical record.” The chapter also recommends that: “All ICUs should be able to train staff in intensive care ultrasound” and “ICUs should foster robust quality assurance processes, including peer review of image and reporting quality.” Clearly there are challenges to be met in the delivery of timely echocardiography and associated governance structures, however the Faculty of Intensive Care Medicine is committed to supportive influence in this area of practice. With kind regards Dean, FICM
Chief Medical Officer, Responsible Officer & Consultant Physician
Direct Dial:
Email:
Tel: 01733 678000
(If DDI prefix extension no. with 67)
Peterborough City Hospital
Bretton Gate
Peterborough
PE3 9GZ
Executive Assistant:
Email :
Our Ref:
30th May 2025
Mr D Heming
Senior Coroner for Cambridgeshire & Peterborough
The Coroner’s Office
Lawrence Court
Princes Street
HUNTINGDON
PE29 3PA
Dear Sir,
Inquest into the Death of Christian HOBBS
I refer to your Regulation 28 Report.
Before I respond to the specific issues raised in the Report, there are a few key points
that I believe it necessary to highlight.
Firstly, the inquest hearing into Christian’s death did not commence until October
2022, almost five years after Christian’s tragic death. It was then part adjourned and
resumed a year later in October 2023 with the Conclusion delivered in October 2024,
almost seven years after Christian’s death. By this time, the Trust had already made
numerous changes and quality improvements based upon its internal investigation
and lessons learned from this case.
Secondly, our own investigation highlighted that the Emergency Department Registrar
who assessed Christian on his admission to ED failed to diagnose cardiogenic shock
caused by his undiagnosed cardiomyopathy. Instead, the diagnosis given was septic
shock. However, as clinicians, whilst we often see patients who do suffer from
cardiogenic shock, this tends to be in much older patients with ischaemic heart
disease. Cardiogenic shock in a young person who has essentially been previously fit
and well is extremely rare and most clinicians will never come across such a situation
in their entire careers. The extreme rarity of this condition makes it extremely difficult
to diagnose, especially in a situation which is time critical. Conversely, sepsis is a far
more common cause of admission in young people of Christian’s age, and it is widely
recognised by healthcare staff and the public alike.
Moving on to the specific issues that you have raised in your Report:-
A.
B.
C.
D.
Cardiogenic shock
Our focus as a Trust since this case has been to concentrate on education and
training of our staff to be aware of, and to recognise, cardiogenic shock in
patients of a young age, especially in the ED setting, and to escalate
accordingly.
Echocardiography
This case was not caused by an inability to perform an echocardiogram. Had
cardiogenic shock been suspected, a Consultant Intensivist or an on duty
Medical Registrar, who was also a trained Cardiology Registrar, could have
performed the procedure. As was explained at the inquest hearing in October
2023, it is possible to train more clinicians to perform echocardiograms.
However, for a clinician to maintain their accreditation to perform
echocardiograms, it is obligatory to perform a certain number of
echocardiograms annually. While Cardiologists and Intensivists routinely meet
this requirement, it remains challenging for other specialty clinicians, including
ED. Nevertheless, our trainees now receive echocardiography training.
Fluid Management
The Trust acknowledges historical concerns regarding fluid management and
the maintenance of fluid balance charts, but significant training and education
have since been provided. In Christian’s case, gaining intravenous access was
challenging due to hypoperfusion caused by cardiogenic shock, resulting in
fluids being administered later than ideal, leaving minimal time to evaluate the
response.
Team Interactions
As a result of the time it took for the inquest to take place, several clinicians
were no longer working at the Trust by the time the hearing was commenced.
Significantly, the ED Registrar was no longer working in this country and,
despite efforts by your Office, it was not possible to locate him in order for him
to give evidence regarding the events which occurred on the 26th December
2017. His evidence would have been crucial, as he was the clinician who
initially assessed Christian and arrived at the diagnosis of sepsis secondary to
a chest infection. Given Christian’s symptoms, an infection was plausible and
may have precipitated heart failure leading to cardiogenic shock. However, his
critical condition on admission was not fully appreciated. Had this been
recognised, existing escalation mechanisms, including an urgent review by the
ED Consultant, who was also an Intensive Care Medicine Consultant, could
have been utilised. Following a referral by ED to the General Physicians,
patients are normally seen in time order unless there is a specific concern
regarding the patient’s condition. In those circumstances, the General
Physicians would have been asked to see Christian immediately. The more
likely scenario in Christian’s case is that the Consultant in charge of ED that
day would have been asked to see the patient on an urgent basis. The
mechanisms are present for escalation, but the issue was a failure to recognise
that Christian’s poor condition was due to cardiogenic shock.
E.
Radiology Within NWAFT
The ED Registrar requested a number of investigations after assessing
Christian. One of these investigations was a chest x-ray. This was performed
after the assessment had been completed and Christian referred to the General
Physicians. By that stage, the ED Registrar was treating other patients and he
therefore did not view the chest x-ray.
Although there is some evidence to suggest that the chest x-ray was viewed by
a member of the Medical team before they had the opportunity to assess
Christian, no gross abnormality was noted at that time. The x-ray was an AP
view and it is not possible to accurately assess the size of the heart in such a
projection.
Plain films are usually formally reported within 24-48 hours. Furthermore, where
necessary, a clinician can also request an urgent formal report from a Trust
Radiologist, 7 days a week.
G.
Blood Gases/Elevated Lactate
The sepsis guidelines are clear and once sepsis is suspected a venous blood
gas should have been obtained when the initial blood samples were obtained at
19:00h. The Trust has since expanded its sepsis education and training,
employing dedicated sepsis nurses who deliver the education and training, and
monitor adherence to protocols and hold bi-monthly sepsis meetings.
H.
Critical Care
Your concern here appears to relate to a case at Hinchingbrooke Hospital from
2019. I cannot see any concerns regarding the care provided to Christian by
the Critical Care clinicians. Christian was managed entirely within the
Emergency Department at Peterborough City Hospital. Following his cardiac
arrest, the ICU clinicians took over his care and were responsible for
resuscitation.
Differential Diagnosis
The diagnosis in Christian’s case was one of sepsis/septic shock with
cardiogenic shock overlooked due to its rarity in young patients. Differential
diagnoses are a fundamental part of medical training and we are not aware of
this being a recurring theme.
Sepsis Pathway
I have dealt with the issue of sepsis in point G above.
Anti-emetic medication
The paper referenced from July 2024, seven years after Christian’s death,
suggests potential risks associated with Cyclizine. Cyclizine is a very commonly
used anti-emetic. It is possible that it may not have been used if a diagnosis of
cardiogenic shock had been made. However, as explained previously, at the
I.
J.
K.
L.
M.
N.
O.
time Cyclizine was prescribed it was not known that Christian had a
cardiomyopathy and was in cardiogenic shock. The working diagnosis was
sepsis. Clinicians in both ED and ICU have now been made aware of the
potential complications of Cyclizine.
ECG analysis
All ECGs performed in the Emergency Department must be signed off by a
Consultant or Registrar. Christian’s ECG on admission revealed a sinus
tachycardia. ECG training remains an important part of training for resident
doctors.
Record-keeping
The maintenance of good documentation is something which is highlighted to
all clinicians during their training and postgraduate education. In addition, the
Trust introduced the Symphony medical records system (digital) into the
Emergency Department in December 2018 and this has resulted in
improvements in record-keeping. The issue of the jugular venous pressure and
capillary refill time is not a matter related to documentation; it is an issue which
relates to an incomplete examination by the ED Registrar. Once again, it is
difficult to comment upon this in the absence of any evidence from the clinician.
However, these issues have been highlighted to staff in ED.
Data from Emergency Department Alarms
The parameters at which alarms are sounded can be adjusted by staff on a
temporary basis. Notwithstanding this, the monitors are still visible to staff in
the Resuscitation area. As was explained at the inquest, the Emergency
Department has subsequently installed a central monitoring area with printers.
There is therefore no problem in retaining or printing off data if this is required.
Unfortunately, in Christian’s case, the Trust was not informed of any concerns
in this respect until some considerable time after Christian’s death. The
monitors that we had at that time would needed to have been interrogated prior
to being used on the next patient. This is no longer an issue with the new
equipment that we have but once again data will only be stored for a limited
period of time.
Learning from HSSIB Reports
The issues raised in the 2019 report align with NICE Guidelines and the
National Early Warning Score (NEWS) tool developed by the Royal College of
Physicians, both of which support early detection of acute illness and timely
escalation of the deteriorating patient. I can confirm that the Trust’s
Physiological and Neurological Observations Policy (Version 6, approved on 22
August 2024) is based upon these national guidelines. Additionally, as part of
the Trust’s PSIRF (patient safety incident response framework) priorities, we
have commenced an improvement plan focusing on the NEWS2 score to
enhance the management of deteriorating patients. Any patient who may have
been harmed through deterioration, is discussed at the weekly PSIRP meeting
with a view to proceeding to a formal investigation of the case.
You will, of course, also be aware that Martha’s Rule (in relation to escalation)
has been introduced at a national level and introduced on both our main sites.
P.
S.
Patient Safety In Some Trust Areas
It is unclear which specific concerns are being referenced or how these relate to
this inquest. However, since January 2017 your Office has issued five
Regulation 28 Reports directed at the Trust. All recommendations contained
within those reports have been actioned. The Trust is also subject to regular
reviews by the CQC and we work with the CQC to ensure all recommendations
are implemented.
NWAFT Paediatric Mortality Review
Christian’s death was initially discussed by the Paediatricians at a Review
meeting on the 22nd February 2018 but as the results of the Post Mortem were
not yet available, a further discussion took place on the 26th June 2018. At that
point, no concerns had been received regarding Christian’s management in ED.
At the meeting it was noted that the PM findings had been of a possible intrinsic
cardiomyopathy. The Consultant Paediatricians therefore felt that as a result of
this finding other family members should be screened for a possible metabolic
cause. The GP Practice was therefore contacted. The GP confirmed that the
family had already been referred for screening.
I hope that this response does assure you that there have been significant changes
implemented at the Trust since Christian’s death in 2017. We acknowledge the
lessons learned from this tragic event and remain fully committed to ensuring they are
reflected in the ongoing training and education of our clinicians.
Yours faithfully,
Chief Medical Officer, Responsible Officer & Consultant Physician
Mr David Hemming Cambridgeshire & Peterborough Coroners Service Lawrence Court Princes Street Huntingdon PE29 3PA NSCP Business Office, c/o North Northamptonshire Council Bowling Green Road Kettering NN15 7QX Email: Date: 29.05.2025 Dear Mr Hemming, RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I am responding on behalf of the Northamptonshire Safeguarding Children Partnership to your report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 08 April 2025, following the tragic death of Christian Hobbs on 26 December 2017. Specifically, "POINT R – CHILD DEATH OVERVIEW PANEL REVIEW." Northamptonshire Child Death Overview Panel is a Northamptonshire Safeguarding Children Partnership (NSCP) subgroup, and I am the current CDOP chair. (CDOP) I am unable to comment on why Northamptonshire CDOP agreed that there were no modifiable factors in the review of Christian's death. The CDOP minutes from 12 March 2019, where case Northants498 (Christian Hobbs) was discussed, are brief. The minutes state that case Northants498 was discussed and that CDOP members identified no modifiable factors. As the Report notes, the 'analysis form' is not available, and thus, I cannot determine what information was shared with the Northamptonshire CDOP panel to inform their discussion. Specifically, whether the "…significant issues on clinical management" referenced in the Report were shared with CDOP. I can offer assurance regarding the current child death review process and the operation of Northamptonshire CDOP. All CDOP forms and associated communication are now collected, collated and stored appropriately per the General Data Protection Regulation. Ensuring all relevant information is available supports a comprehensive review of the deaths of children and young people in Address: NSCP Business Office, c/o North Northamptonshire Council, Kettering Offices, Bowling Green Road, Kettering, NN15 7QX Tel: E-Mail: Website: 07872 148334 NSCP@northnorthants.gov.uk www.northamptonshirescb.org.uk Northamptonshire. The child death review process operates in line with national guidance, ensuring we respond swiftly to national practice changes. The Designated Doctor for Child Deaths, the Child Death Review Coordinator and the CDOP Chair actively maintain their knowledge and skills through CPD and participating in regional CDOP meetings. The Designated Doctor for Child Deaths, the Child Death Review Coordinator have shadowed CDOP meetings in in neighbouring Northamptonshire. development inform the authorities ongoing CDOP to of Robust joint agency response (JAR) processes align with the national guidance regarding unexpected deaths in children. The Designated Doctor for Child Deaths, the Child Death Review Coordinator and the CDOP Chair (the CDR Team) display' professional curiosity' regarding unexpected deaths in children and seek further information to inform decision- (SI) making. investigations, similar processes, and circumstances suggest they are warranted, the team challenges the organisation concerned, escalating to senior leaders for support if needed. the CDR team believes organisations don't plan serious incident If Where a child or young person dies outside of Northamptonshire, and child death professionals from the area where they died lead the initial JAR process, there is communication with the Northamptonshire CDR team to ensure a thorough process is followed continuously. Northamptonshire CDOP members will have access to the JAR notes to support decision-making regarding whether a death is considered modifiable. The CDR team review SI reports and those from similar investigative processes. If they have concerns that the report findings don't reflect the issues associated with the child's death and/or the improvement actions don't sufficiently address the issues identified, the CDR team will seek further information from the organisation. If the team still has concerns, they elevate them through the ICB quality team. When reviewing the deaths of children where there has been an SI investigation, CDOP will identify modifiable factors related to the service provision, which echo those found in the investigation and others CDOP believe to be important. This mirrors practice in other CDOPs I've chaired. The CDR team reached a joint decision on when to bring a case to CDOP. Typically, children and young people's deaths are not usually discussed until formal processes, such as serious incident (SI) investigations or inquests, have concluded. Delaying the CDOP panel ensures that the SI investigation reports, and inquest conclusions inform the CDOP discussion. When the CDR team knows that inquests will be delayed, they decide whether to have an initial discussion at CDOP to identify learning. If so, the case will be returned to CDOP for further discussion and ratification. At the time of Christian's death, there was no CDR Coordinator in the post. The CDR Coordinator is crucial including their concerns regarding their child's care. The CDR Coordinator advocates for families with in ensuring that the family's voices are heard, Address: NSCP Business Office, c/o North Northamptonshire Council, Kettering Offices, Bowling Green Road, Kettering, NN15 7QX Tel: E-Mail: Website: 07872 148334 NSCP@northnorthants.gov.uk www.northamptonshirescb.org.uk concerns and ensures families have answers to their questions wherever possible. The Northamptonshire CDOP panels operate well. All members have an equal voice. If one CDOP member raises a concern or wants to discuss whether factors are modifiable, other members listen, and there is an open and honest discussion. Northamptonshire CDOP is the third CDOP panel I've chaired or co-chaired and I draw on my experience, alongside the experience of colleagues to ensure we have a cycle of continuous improvement. I am confident what constitutes good practice in reviewing child deaths and committed to enshrining it in Northamptonshire. Your Sincerely, Chair of Northamptonshire Child Death Overview Panel Deputy Director of Public Health, North Northamptonshire Council Address: NSCP Business Office, c/o North Northamptonshire Council, Kettering Offices, Bowling Green Road, Kettering, NN15 7QX Tel: E-Mail: Website: 07872 148334 NSCP@northnorthants.gov.uk www.northamptonshirescb.org.uk
Senior Coroner David Heming
Lawrence Court
Princes Street
Huntingdon
PE29 3PA
19 May 2025
Dear Mr Heming,
Further to your Prevention of Future Deaths (PFD) Notice issued on 07.04.2025 following the
conclusion of your inquest (14th October 2024) into the death of Christian Hobbs (aged 17yrs) who died
on 26th December 2017, we would like to extend our sympathy and condolences to Christian’s family
and friends.
Christian attended the emergency department (ED) of the Peterborough City Hospital with symptoms
of palpitations, chest tightness, cough, aching and vomiting; he was found to be tachycardic and
hypotensive. Christian was moved to the ED resus area where he was initially managed for potential
sepsis, which included one litre of intravenous (IV) fluids, IV antibiotics, as well as an IV antiemetic
(Cyclizine). Investigations undertaken included an ECG (reported as sinus tachycardia) as well as blood
tests which included lactate level (raised). Christian’s condition rapidly deteriorated and he had a
cardiac arrest, which was treated with cardiopulmonary resuscitation; including defibrillation,
magnesium and amiodarone infusions as well as intubation. The cardiac arrest team was made up of
senior ED, intensive care and medical doctors. Return of spontaneous circulation (ROSC) was achieved
and Christian continued to receive inotropic support and the intensive care consultant undertook a
bedside echocardiogram which showed septal wall akinesia and a filled inferior vena cava.
Unfortunately, despite extensive inotropic support, treatment for hyperkalaemia, and mechanical
ventilation, Christian’s condition continued to deteriorate and he very sadly died. The cause of death
was a previously undiagnosed cardiomyopathy leading to cardiogenic shock and multi organ failure.
From your report, the RCEM feels that the initial clinical management in this case was appropriate given
the greater likelihood of infection or sepsis being the cause of Christian’s presentation than the much
less likely diagnosis of cardiomyopathy. We further feel that the clinical management plan which
prioritised the delivery of time critical therapy followed by an assessment to see if the interventions had
been effective was appropriate.
Point B – Echocardiography. Regarding your concern that echocardiography was not performed prior
to cardiac arrest, we can confirm that the RCEM training curriculum at the time [1] did not include cardiac
ultrasound for the purposes of shock assessment, it was only included as an adjunct in the setting of
cardiac arrest. It would therefore have been an unreasonable expectation that a focused cardiac
ultrasound for the assessment of shock should have taken place before cardiac arrest by the emergency
medicine doctor. A subsequent curriculum update in 2021 did include focused cardiac ultrasound for
shock assessment for emergency medicine doctors in their last years of training [2]. The RCEM also
provides learning resources for members regarding the use of point of care ultrasound (POCUS) in
shock [3]. It is difficult for the RCEM to comment with any degree of certainty on whether a focused
cardiac ultrasound for assessment of shock prior to Christian’s cardiac arrest would have made any
significant difference in this case. We note your PFD notice also references issues regarding the access
to and the provision of emergency echocardiography services in acute hospitals and we share your
concerns, as it is unrealistic to assume that all emergency medicine doctors will be proficient at
providing focused cardiac ultrasound for the assessment of shock, despite RCEM’s updated trainee
curriculum.
Point K – Antiemetic medication. We agree that some anti-emetic medication can cause arrhythmias
for example by prolonging the QT interval (e.g. Prochlorperazine {common} and Ondansertron {rare or
very rare}) [1]. Christian was given the single anti-emetic cyclizine which the British National Formulary
(BNF) [4] suggests may possibly be a cause of arrhythmias but it is unable to quantify the frequency of
this side-effect as it occurs less than ‘very rarely’ (frequency not known). We are mindful that at the
time when the clinical team made the decision to give an anti-emetic they were unaware of Christian’s
undiagnosed underlying heart condition (cardiomyopathy). Regarding the academic publication in your
PFD notice [5], we note this case involved the use of three different anti-emetic agents in the same
patient, including two agents which are highlighted by the BNF as causing QT prolongation
prochlorperazine, ondansertron in-addition to cyclizine. However, despite our uncertainty regarding the
contribution of cyclizine to Christian’s deterioration, we do feel that a safety communication with RCEM
members would be worthwhile and valuable. The safety communication will highlight which commonly
used anti-emetics are known to prolong the QT interval or promote arrhythmias, especially since the
use of ondansertron in EDs has increased considerably since 2017. We undertake to do this before
April 2026.
Point L – ECG Analysis. We note that on arrival in the ED, Christian had a significant tachycardia which
would have made the diagnosis of any underlying structural heart defect especially difficult even for the
most experienced emergency medicine clinician. The RCEM supports emergency departments in
helping to ensure that emergency medicine clinicians are able to interpret electrocardiograms (ECGs)
by providing a number of online resources including general ECG interpretation [6] as well as
tachycardias seen in the resus room [7]. The latter also makes reference to drugs which may cause
QT prolongation. The RCEM curriculum also includes ECG interpretation as a core skill [8]. Regarding
the academic publication in your PFD notice [9] we note that this study only included 42 UK doctors
and did not include emergency medicine doctors and highlights the good practice of their local
emergency department which has a policy of only allowing registrars who have undergone specific
competency training in ECG interpretation to be allowed to ‘sign off’ ECGs; the inference seems to be
that this ED policy should be replicated by the rest of the hospital.
Thank you for bringing these issues to our attention and for providing such a comprehensive report
regarding this extremely sad and tragic event.
Yours sincerely,
Chair, Quality in Emergency Care Committee
Royal College of Emergency Medicine
References
1 C_inetpubwwwrootmedicalcemUploaddocumentzCEM8489-RCEM 2015 Main Curriculum
-
Applicable from August 2016 (approved 23 Nov 2015) (Aug 2016 update1).pdf (Accessed 01.05.2025)
2 SLO 6 - Proficiently deliver key procedural skills needed in Emergency Medicine - RCEMCurriculum
(Accessed 01.05.2025)
3 https://www.rcemlearning.co.uk/reference/ultrasound-assessment-of-patients-in-shock/ (Accessed
01.05.2025)
4 The British National Formulary, Royal Pharmaceutical Society. https://bnf.nice.org.uk/ (Accessed
11.04.2025)
5 Khan A, Kenawi A, Jadhav S et al. (July 09 2024). Ventricular Fibrillation Arrest Triggered by Anti-
emetics Revealing an Underlying Long QT Syndrome in a Young Woman. Cureus16(7): e64136. DOI
10.7759/cureus.64136
6--https://www.rcemlearning.co.uk/modules/doctor-can-you-cast-your-eyes-over-this-ecg-for-me-
induction-course/ (Accessed 11.04.2025)
7 https://www.rcemlearning.co.uk/reference/tachycardias-in-the-resuscitation-room/#1674164879404-
2a75f5d5-f07b (Accessed 11.04.2025)
8 https://rcemcurriculum.co.uk/answer-clinical-questions/#1553791006781-2d6725a6-2b0d (Accessed
02.05.2025)
9 Abdalla A, Khana D (September 29, 2022). Electrocardiography interpretation proficiency among
medical doctors of different grades
the United Kingdom. Cureus 14(9): e29755. DOI
10.7759/cureus.29755.
in
Senior Coroner David Heming Cambridgeshire & Peterborough Coroners Service Lawrence Court Princes Street Huntingdon PE29 3PA 28 April 2025 Sent by email: Dear Mr Heming, RCR Response to Regulation 28: Prevention of Future Deaths report issued on 8 April 2025 in relation to the death of Christian James Gabriel Hobbs. I was very sorry to read about the death of Christian Hobbs and I would like to express my deepest condolences to Mr Hobbs’ family. We take the matters raised in your report very seriously, and I hope this response is helpful in outlining how the Royal College of Radiologists (RCR) is committed to supporting high standards of clinical care, and how we are continuing to learn and advocate for improvements in medical imaging services across the UK. The RCR is a registered charity that works with its members and Fellows to advance medical care across the specialties of Clinical Radiology and Clinical Oncology. We promote excellence in clinical practice and publish a range of standards and guidance to support the delivery of high-quality radiology and oncology services. We understand that this concern primarily relates to local systems and processes, but we would like to take this opportunity to provide a broader context from a national perspective. Under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R), a written evaluation of imaging is required, which may be documented by a referring clinician or a specialist such as a radiologist. While radiologists’ reports remain a cornerstone of imaging interpretation, these are often not contemporaneous due to significant workforce limitations. In such cases, it is expected that referring clinicians record their own evaluation at the time of reviewing the images, particularly when immediate clinical decisions are required. The RCR has long recognised the critical shortage of radiologists in the UK. This issue has been a consistent theme across several other Prevention of Future Deaths reports received in recent years and has been central to our advocacy efforts. As outlined in our 2023 Clinical Radiology Workforce Census Report, the specialty is facing a 30% shortfall in consultant radiologists, projected to rise to 40% by 2028 if no action is taken. The next annual workforce census report will be published in June 2025 but to date there has not been investment anywhere close to what would be required to close that gap. The demand for imaging continues to grow annually, but workforce growth has not kept pace, resulting in significant delays and pressures on the current service. We acknowledge concerns regarding perceived disparities in imaging provision between different centres. While variation exists, it is important to note that certain services such as out-of-hours chest X-ray reporting may be limited in most settings. Our goal is to support a system-wide uplift in imaging services across all settings. To this end, the RCR supports regional imaging networks to enable more equitable access to expertise and resources. We also publish national standards (eg Professional Standards guidance and iRefer) to promote consistent, high-quality reporting regardless of geography. The RCR does not directly run radiology training which is a function of the NHS in all four nations. We are actively engaged in efforts to encourage expansion of radiology training capacity and continue to contribute to national workforce planning conversations and support initiatives aimed at addressing current and future demand. Our vision is one of collective improvement so that all patients, irrespective of location, receive timely and accurate diagnostic care. I am grateful to you for bringing these matters of concern to our attention and for giving us the opportunity to respond. Once again, I do express my deepest condolences to Mr Hobbs’ family and loved ones. Yours sincerely, RCR President
See every Prevention of Future Deaths report matching North West Anglia NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.